Can enhanced perioperative care protocols help children recover from surgery faster, with fewer complications? Encouraged by strong data supporting the practice in adult patients, a multidisciplinary team at Cincinnati Children’s has implemented a perioperative care pathway for children undergoing urologic reconstruction with a possible bowel anastomosis. The quality improvement initiative dovetails with the medical center’s participation in a related multicenter clinical trial that began in 2017.

Surgeons in Europe pioneered enhanced recovery after surgery (ERAS) protocols about 15 years ago, and in 2010 established the ERAS Society, which investigates and publishes evidence-based perioperative guidelines. ERAS protocols – some of which contrast sharply with traditional practices – have been adopted more widely by many surgical subspecialties in the United States in recent years. They are well-studied in the adult population, particularly among colorectal surgery patients, but not in children. “We based our perioperative care pathway on the existing literature and ERAS Society guidelines,” says pediatric urologist Andrew Strine, MD, who leads the multidisciplinary team of pediatric urologists, anesthesiologists and nurses. “They include 20 strategies that focus on enhancing quality of care, preventing complications, improving surgical outcomes and improving the patient and family experience. It is a multimodal approach that requires engagement across the continuum of care.”

Among the protocol’s interventions are:

• Avoiding prolonged fasting and giving a carbohydrate-rich beverage before surgery to achieve a metabolically fed (rather than fasting) state. This practice is associated with a decreased length of stay, and research shows that it does not cause pulmonary complications.
• No bowel preparation. Bowel preparation is not associated with any benefit in multiple meta-analyses, and is associated with potential disadvantages, such as electrolyte abnormalities and dehydration.
• Minimal use of narcotic pain relief during and after surgery to limit side effects such as nausea, vomiting and a slow gut. The hospital’s acute pain service and anesthesia team provide alternative strategies, including regional anesthesia and epidural pain control.
• Early feeding after surgery to promote a return of bowel function and prevent a loss of lean body mass and impaired wound healing.
• Early mobilization after surgery to promote a return of bowel function and prevent deconditioning.

“An important aspect of this protocol is educating families about all of these measures and what we are trying to achieve,” Strine says. “We have established a continuous audit process to evaluate adherence to the protocol and assess its effectiveness in areas such as length of stay, post-surgical pain control, complications, readmissions and quality of life.”

As part of its commitment to ERAS, Cincinnati Children’s is participating in a multicenter pilot and exploratory study called “Pediatric Urology Recovery after Surgery Endeavor (PURSUE).” Participating institutions also include Children’s Hospital Colorado, Children’s Hospital St. Louis, Children’s Hospital of Pittsburgh, Mercy Children’s in Kansas City and SickKids International in Toronto. Investigators have agreed upon a perioperative care pathway, and will explore whether adhering to these protocols improves outcomes in patients undergoing urologic reconstruction with a possible bowel anastomosis. Enrollment has already begun, and will include as many as 100 patients at the six sites.